Basic Information
| Provider Information | |||||||||
| NPI: | 1235471954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KADLEC REGIONAL MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 SWIFT BLVD | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099464611 | ||||||||
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| Address1: | 888 SWIFT BLVD | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099464611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REIMBURSEMENT ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KADLEC REGIONAL MEDICAL CENTER | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 602421635 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 208200000X | 602580652 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1972507580 | 05 | WA | MEDICAID | 025904 | 01 | WA | L&I GROUP # | OTHER |